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Ministry of Health - By BC Physicians, for BC Physicians

Chronic Kidney Disease - Identification, Evaluation and Management of Patients

Effective Date: September 15, 2008

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics


The first part of this guideline provides recommendations for the investigation and evaluation of adult patients (19+) at risk for chronic kidney disease (CKD). The second part of this guideline focuses on the management of adult patients with known CKD and includes care objectives and patient self-management.

Specialized management of established CKD, e.g. erythropoietic agents for anemia, renal replacement therapy, and treatment of calcium, phosphate, or parathyroid hormone (PTH) abnormalities is beyond the scope of this guideline.

Diagnostic Code: 585 (chronic renal failure)

Part 1: Identification and Evaluation of Patients at Risk for CKD

This section covers:

  • Prevention and risk factors
  • Investigation
  • Diagnosis and staging of CKD
  • Determining the cause of CKD
  • Evaluating patients with abnormal screening tests
  • Flow diagram for evaluating and managing suspected CKD

I. Prevention and risk factors

Identify patients at risk for CKD based upon a directed medical and surgical history including co-morbidities (e.g. diabetes, cardiovascular disease [CVD]) and dietary, social, demographic and cultural factors, a review of symptoms, and physical examination. Populations at increased risk include those with:

  • Diabetes
  • Hypertension with or without CVD
  • A family history of kidney disease
  • Specific high-risk ethnic groups: First Nations, Pacific Islanders, African descent and Asians

Note: Age > 60 years is associated with an increased risk of impaired kidney function, but evidence is insufficient to recommend screening solely on the basis of age.

II. Investigation

It is recommended that physicians screen at-risk populations every 1-2 years depending upon clinical circumstances (e.g. yearly for persons with diabetes) using serum creatinine and random urine tests (macroscopic/microscopic urinalysis and ACR). Estimated glomerular filtration rate (eGFR) is the best marker for CKD and is computed from the serum creatinine. Most labs in

British Columbia (BC) automatically report eGFR when a serum creatinine is ordered. (See Appendix B for further information on eGFR calculations.)

Investigational tests

a)Serum testing: eGFR values:

  • < 60 mL/min and persistent (present for > 3 months) indicates substantial reduction in kidney function.
  • > 60 mL/min and < 100 mL/min, in the absence of urine abnormalities or structural abnormalities on imaging studies (e.g. ultrasound), does not indicate kidney disease.
  • Age > 75 years: accuracy of eGFR for patients over 75 is questionable and may underestimate true kidney function. Values of eGFR < 45 should be considered as a likely indicator of decreased renal function and merit further work-up. Values between 45 and 60 may reflect normal variation in the absence of other conditions, however, caution is still recommended with respect to medications, dye, and risk of acute kidney injury with severe illnesses. Correlation with clinical condition is recommended.1
  • Age > 85 years: equation for eGFR is problematic and risk of progression of CKD is not known. In the absence of other metabolic or hematological abnormalities, a conservative approach is recommended. Values between 45 and 60 may reflect normal variation in the absence of other conditions. Caution is still recommended with respect to medications, dye, and risk of acute kidney injury with severe illnesses.
  • Estimates based on serum creatinine measurements (eGFR) may be unreliable in patients with very large or small body habitus, those on specific diets (very high or very low protein), and in patients receiving medications that interfere with the excretion of creatinine (e.g. trimethoprim and sulfamethoxazole, ciprofloxacin, fenofibrate).
  • Exercise, diet and/or hydration status may affect kidney function estimates or the degree of albuminuria/proteinuria. If baseline tests are abnormal or subsequent tests are significantly different from baseline, confirmation by repeat testing is warranted.

b)Urine testing: macroscopic/microscopic analysis and albumin/creatinine ratio (ACR) values

  • Random urine tests for macroscopic/microscopic urinalysis and ACR:
    • Significant abnormalities: persistent white blood cells or red blood cells in the absence of infection or instrumentation; presence of any cellular casts is always pathological.
    • ACR elevation (> 2.0 mg/mmol males; > 2.8 mg/mmol females) on 2 out of 3 serial tests performed 1 week to 2 months apart indicates micro-vascular disease +/- glomerular disease.
  • Urine test abnormalities, even with persistent eGFR values ≥ 60 ml/min, indicate abnormal kidney function, either as an isolated condition or as a symptom of a systemic disease.
  • 24-hour urine collections are not necessary in most cases.
  • ACR is the method that allows one to test for albumin present in quantities above normal but below the detectable range on standard dipsticks. In the past, the word microalbumin has been used, but this may lead to a false impression that there is a different molecule when there is not. Thus, ACR is the preferred method by which to assess abnormal levels of albumin. Note that this guideline uses the thresholds adopted by the Canadian Diabetes Association for the detection of microalbuminuria. As methods improve and further data becomes available, these cutoffs may be revised. Serial ACR tests can normally be incorporated into the routine visit schedule.

Acting on test results

  • Normal: repeat annually or as clinically indicated and monitor blood pressure.
  • Abnormal: confirm and evaluate (Table 1 below).

III. Diagnosis and staging of CKD

CKD is defined as eGFR < 60 mL/min for > 3 months, or evidence of kidney damage (pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies). If CKD is present, determine its stage based on eGFR, urinalysis, and ACR. The following staging system, designed by the US National Kidney Foundation with international input, is recommended to facilitate assessment and management of CKD.2,3

Table 1. Stages of CKD

(printable PDF)

Table 1. Stages of CKD

IV. Determining the cause of CKD

Impaired kidney function is often multi-factorial. If possible, determine a primary cause of kidney disease in all patients. Kidney ultrasound is a useful examination to identify polycystic kidney disease, cancer, stones, and obstruction. Discrepancy in kidney size may signal clinically significant renal artery stenosis (the work up for renal artery stenosis is beyond the scope of this guideline).

Even if a primary cause seems obvious (e.g. hypertension, diabetes), the possibility of a serious underlying disorder (e.g. vasculitis, systemic lupus erythematosis) must be considered in patients with:

  • Abnormal urinalysis, e.g. proteinuria, hematuria, cellular casts, or combinations thereof.
  • Rapid sustained decline in kidney function (ΔeGFR > 10-15%/year) despite remedy of reversible precipitants e.g. volume contraction, febrile illness, medications.
  • Consistent impairment of kidney function in the absence of risk factors.
  • Constitutional symptoms suggesting systemic illness.
  • Sudden or severe onset of symptoms, e.g. edema unrelated to heart or liver disease.

    Refer to an internist or nephrologist for further evaluation if an etiology cannot be determined. Note that occasionally a screening test will identify a serious systemic disease or early stages of an acute illness. In patients with active urine sediments (rbc casts or cellular casts ± protein), constitutional symptoms, or unexplained severity of kidney dysfunction, prompt consultation with a specialist and/or re-evaluation of tests is indicated.

V. Evaluating patients with abnormal screening tests

Patient management should reflect CKD stage and eGFR, urinalysis and ACR results (see Table 2).

Table 2. Evaluating patients with abnormal screening testsa

(printable PDF)

Table 2. Evaluating patients with abnormal screening tests

Figure 1. Flow Diagram for Evaluating and Managing Patients with Suspected CKD

(printable PDF)

Figure 1. Flow Diagram for Evaluating and Managing Patients with Suspected CKD

Part 2: Management of Patients with Established CKD

This section covers:

  • Identifying care objectives and targets
  • Practice points for goal setting
  • Supporting patient self-management
  • Meeting care objectives

I. Identifying care objectives and targets

Physicians will ideally identify care objectives for all patients with CKD (see Table 3). Depending on the level of kidney function and complexity of therapy required, these care objectives may be more or less difficult to achieve without help from a specialized team of health care professionals including a nephrologist. Treatment goals must be tailored to the individual.

Table 3: Care objectives and targets

(printable PDF)

Table 3: Care objectives and targets

II. Practice points for goal setting

When setting goals with your patient, consider the following:

  • Exercise, diet, and/or hydration status may affect kidney function estimates or the degree of albuminuria/proteinuria. If baseline tests are abnormal or subsequent tests are significantly different from baseline, confirm by repeat testing.
  • Rigorous control of BP has been shown to reduce the risk of complications and mortality rates. In particular, the inhibition of the renin angiotensin system with ACE inhibitors or ARBs has been shown to be very effective. Diuretics, ß-blockers, and/or calcium channel blockers may also be required since most patients require more than two medications to reach target values.9 See BC guideline: Hypertension - Detection, Diagnosis and Management.
  • Every adult with kidney disease may be at increased risk of cardiovascular disease.4,10
  • Nephrotoxic medications (e.g. NSAIDs, COX-2 inhibitors, aminoglycosides) should be avoided or used with caution in patients with even mild kidney impairment (eGFR 60-90 mL/min with evidence of kidney damage), and kidney function should be monitored if they are used.
  • IV or intra-arterial radiocontrast use poses a high risk of acute kidney injury in patients with Stage 4 or 5 CKD and a moderate risk in patients with Stage 3 disease.11 If imaging is required, alternate imaging techniques, including MRI angiography, should be considered for these patients. If no alternative exists and the procedure is medically necessary, the patient should provide written informed consent and protection with IV hydration and N-acetyl cysteine may be used according to a published protocol, or in consultation with nephrologists.12
  • Patients with CKD are at high risk of further acute kidney injury with volume contraction, e.g. nausea, vomiting, diarrheal illnesses, or the use of certain bowel preparations.
  • Review medication list, identify medications excreted by the kidneys (e.g. metformin, digoxin and lithium) and adjust dosages as appropriate or use alternate treatment.13 (see Physician's Resource section).
  • Rapid deterioration in kidney function (a decline of eGFR >10-15% annually) warrants urgent referral to a nephrologist or internist.
  • Preparation for kidney replacement treatment requires a minimum of 12 months, therefore referral for consideration of kidney replacement should take this into account.
  • Many patients with CKD also have diabetes and/or heart disease. Explaining the linkage between these conditions and how treating one condition benefits others may lessen the psychological impact of several separate diagnoses.14

III. Supporting patient self-management

People with CKD have better outcomes if they take an active role in the management of their own condition and they should be encouraged to do so. Denial, often associated with grief reaction, is common in patients with chronic disease affecting a vital organ. Efforts to introduce preventive lifestyle and medical therapy may fail until understanding and acceptance have been achieved. CKD care teams are skilled at dealing with this issue.

To support patient self-management, the physician should:

  • Support patients through the process of accepting the diagnosis of a chronic illness.
  • Ensure that patients understand the implications of the diagnosis and their role in self- management.
  • Help patients identify a support team.
  • Involve patients in defining the best possible goals for care, including lifestyle modifications such as smoking cessation, healthy diets, weight management, exercise, and social support.
  • Encourage patients to monitor their own progress through the use of diaries or logbooks to track clinical values, and self-monitor BP (and blood glucose where appropriate).
  • Reinforce lifestyle modifications at each visit.
  • Explain and discuss the results of investigations and consultations.
  • Identify community resources that can provide patients with the information, skills and support needed to understand and manage their condition, and direct or refer patients to those resources.
  • Patient self-management resources are listed inChronic Kidney Disease: A Guide for Patients,are available at

IV. Meeting care objectives

The care of CKD patients is very similar to care of any patient with a chronic illness, thus similar principles should be applied. Evidence indicates that the care of chronic diseases such as CKD can be improved by the implementation of regular scheduled reviews of clinical and laboratory parameters.

Physicians are encouraged to:

  • Create a patient register to identify all patients with impaired kidney function in their practice.
  • Participate in a community or provincial patient register wherever possible.
  • Use a flow sheet for each patient with kidney disease. (See Appendix C for sample flow sheet.)
  • Use an organized recall system to ensure that laboratory investigations and subsequent office reviews are performed at regularly scheduled appropriate intervals.
  • Review patient records to ensure care objectives are met.

There is increasing evidence that at lower levels of eGFR, patients benefit from inclusion in multidisciplinary clinics. It is recommended that primary care physicians seek opportunities within their communities to ensure these resources are accessed.15,16,17


This guideline outlines strategies that may help the primary care practitioner meet the complex needs of persons with CKD, including accurate and timely diagnosis, exploration of its etiology, and appropriate management of common factors affecting progression and co-morbid conditions.

CKD is a serious population health problem with a significant impact on individuals, families, society, and health services. It is often associated with other common chronic diseases such as diabetes, hypertension, and heart disease. Based on population studies, the estimated prevalence of significant kidney impairment (eGFR < 60 ml/min) in British Columbia is 145,000 people, approaching the prevalence of Type II diabetes; however, because many cases are undiagnosed, this is likely a true significant underestimate.

There is increasing awareness of CKD in all practices.18 CKD increases the risk of cardiac morbidity and mortality to levels ten times that of population mean risk in addition to placing persons at risk of end stage renal disease requiring dialysis.19,20 Recent studies have demonstrated that the presence of impaired kidney function worsens prognosis for length of hospital stay, morbidity, and mortality.4,10,21,22,23 Thus, while not all people with kidney disease will require dialysis, they are all at higher risk for poor outcomes, adverse reactions to medications and interventions, and episodes of acute kidney failure.4,21,24,25

The outcome of patients who go on to dialysis remains poor with ten per cent annual mortality; the overall five-year survival rate is worse than that of all cancers except cancer of the lung.26 Evidence clearly indicates that efforts to control hypertension and proteinuria (and hyperglycemia in persons with diabetes) can prevent or postpone the development of progressive kidney function decline.7,8,27,28,29,30,31,32,33,34 However, levels of care for milder stages of CKD remain suboptimal and practitioners often do not provide screening and management in accordance with published guidelines.35,36,37

The efficacy of statins in a population with CKD is currently under evaluation in the SHARP trial.38 Until the results are reported, basic risk reduction approaches are recommended as provided in the BC clinical practice guideline,Cardiovascular Disease - Primary Prevention.39 For people without heart disease, a Framingham risk-based approach to treatment with statins is suggested for people with a ten-year coronary heart disease (CHD) risk of 20% or more. Treatment of the high risk population should be to an LDL target of 2.5 mmol LDL/L or a ratio of TC/HDL of < 4.

The BC clinical practice guideline, Diabetes Care, recommends a risk-based approach for lipid management with treatment to an LDL target of 2.5 mmol/L for high-risk patients (> 20 % CHD risk using the UKPDS calculator).40 This approach is consistent with the recent ASPEN trial which showed no benefit using statins for people with low to moderate risk of CHD (low risk, 12% smokers)41 and the CARDS trial, which showed a benefit for population at higher-risk (23% smokers).42 For elderly patients (70+ years), the PROSPER trial found that statins did not reduce CHD and stroke events in men and women without CHD.43


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This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.


Appendix A - Physician Resources

Appendix B - Calculating eGFR: Conversion Table

Appendix C - Chronic Kidney Disease Flow Sheet

Appendix D - Chronic Kidney Disease - A Guide for Patients

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.

Contact Information
Guidelines and Protocols Advisory Committee
Victoria BC V8W 9P1
Web site:


Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.